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Partain DK, Santivasi WL, Kamdar MM, Moeschler SM, Tilburt JC, Fischer KM, Strand JJ. Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey. J Pain Symptom Manage 2024:S0885-3924(24)00735-8. [PMID: 38677489 DOI: 10.1016/j.jpainsymman.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
CONTEXT Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists. OBJECTIVES To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness. METHODS A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs. RESULTS The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians. CONCLUSION This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.
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Affiliation(s)
- Daniel K Partain
- Division of Community Internal Medicine (D.K.P., J.J.S.), Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota, USA.
| | - Wil L Santivasi
- Department of Medicine (W.L.S.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Mihir M Kamdar
- Section of Palliative Care and Geriatric Medicine (M.M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Anesthesia Pain Medicine (M.M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Susan M Moeschler
- Division of Pain Medicine (S.M.M.), Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jon C Tilburt
- Department of General Internal Medicine (J.C.T.), Mayo Clinic, Scottsdale, Arizona, USA
| | - Karen M Fischer
- Quantitative Health Services (K.M.F.), Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob J Strand
- Division of Community Internal Medicine (D.K.P., J.J.S.), Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota, USA
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2
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Estell MH, Whitford KJ, Ulrich AM, Larsen BE, Wood C, Bigelow ML, Dockter TJ, Schoonover KL, Stelpflug AJ, Strand JJ, Walton MP, Lapid MI. Music Therapy Intervention to Reduce Symptom Burden in Hospice Patients: A Descriptive Study. Am J Hosp Palliat Care 2024:10499091241237991. [PMID: 38501668 DOI: 10.1177/10499091241237991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
Background: Music therapy (MT) offers benefits of improved symptom relief and quality of life at the end of life, but its impact on hospice patients and caregivers needs more research. Objective: To assess the impact of MT intervention on symptom burden and well-being of hospice patients and caregivers. Methods: A total of 18 hospice patients, selected based on scores ≥4 on the revised Edmonton Symptom Assessment System (ESAS-r) items on pain, depression, anxiety, or well-being, participated in MT sessions provided by a board-certified music therapist. Over a period of 2-3 weeks, 3-4 MT sessions were conducted for each. Patient Quality of life (QOL) was assessed using the Linear Analogue Self-Assessment (LASA). Depression and anxiety were measured with the Patient Health Questionnaire-4 (PHQ-4). For the 7 caregivers enrolled, stress levels were measured using the Pearlin role overload measure and LASA. Results: Patients reported a reduction in symptom severity and emotional distress and an increase in QOL. All patients endorsed satisfaction with music therapy, describing it as particularly beneficial for stress relief, relaxation, spiritual support, emotional support, and well-being. Scores on overall QOL and stress were worse for caregivers. Conclusion: This study provides evidence that MT reduces symptom burden and enhances the quality of life for hospice patients. Hospice patients and their caregivers endorsed satisfaction with MT. Given the benefits observed, integrating MT into hospice care regimens could potentially improve patient and caregiver outcomes. Larger studies should be conducted to better assess the impact of MT in this population.
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Affiliation(s)
- Madison H Estell
- Medical School, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Kevin J Whitford
- Medical School, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
- Mayo Clinic Hospice, Mayo Clinic, Rochester, MN, USA
- Department of Medicine, Mayo Clinic Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Angela M Ulrich
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Travis J Dockter
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kimberly L Schoonover
- Medical School, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Jacob J Strand
- Medical School, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Monica P Walton
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Maria I Lapid
- Medical School, Mayo Clinic Alix School of Medicine, Rochester, MN, USA
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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3
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Walker LE, Bellolio MF, Dobler CC, Hargraves IG, Pignolo RJ, Shaw K, Strand JJ, Thorsteinsdottir B, Wilson ME, Hess EP. Paths of Emergency Department Care: Development of a Decision Aid to Facilitate Shared Decision Making in Goals of Care Discussions in the Acute Setting. MDM Policy Pract 2021; 6:23814683211058082. [PMID: 34796267 PMCID: PMC8593304 DOI: 10.1177/23814683211058082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 10/17/2021] [Indexed: 11/21/2022] Open
Abstract
Background Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work. Design A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these. Results A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary. Limitations Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis. Conclusions Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients’ values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.
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Affiliation(s)
| | | | - Claudia C Dobler
- Mayo Clinic, Rochester, Minnesota; Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | | | | | | | - Jacob J Strand
- Department of General Internal Medicine Center for Palliative Medicine
| | | | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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4
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Santivasi WL, Childs DS, Wu KL, Partain DK, Litzow MR, LeBlanc TW, Strand JJ. Perceptions of Hematology Among Palliative Care Physicians: Results of a Nationwide Survey. J Pain Symptom Manage 2021; 62:949-959. [PMID: 33933620 DOI: 10.1016/j.jpainsymman.2021.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Palliative care integration for patients with hematologic diseases has lagged behind solid-organ malignancies. Previous work has characterized hematologist perspectives, but less is known about palliative care physician views of this phenomenon. OBJECTIVES To examine palliative care physician attitudes and beliefs regarding hematologic diseases, patient care, and collaboration. METHODS A 44-item survey containing Likert and free-response items was mailed to 1000 AAHPM physician members. Sections explored respondent comfort with specific diagnoses, palliative care integration, relationships with hematologists, and hematology-specific patient care. Logistic regression models with generalized estimating equations were used to compare parallel Likert responses. Free responses were analyzed using thematic analysis. RESULTS The response rate was 55.5%. Respondents reported comfort managing symptoms in leukemia (84.0%), lymphoma (92.1%), multiple myeloma (92.9%), and following hematopoietic stem cell transplant (51.6%). Fewer expressed comfort with understanding disease trajectory (64.9%, 75.7%, 78.5%, and 35.4%) and discussing prognosis (71.0%, 82.6%, 81.6%, and 40.6%). 97.6% of respondents disagreed that palliative care and hematology are incompatible. 50.6% felt that palliative care physicians' limited hematology-specific knowledge hinders collaboration. 89.4% felt that relapse should trigger referral. 80.0% felt that hospice referrals occurred late. In exploring perceptions of hematology-palliative care relationships, three themes were identified: misperceptions of palliative care, desire for integration, and lacking a shared model of understanding. CONCLUSION These data inform efforts to integrate palliative care into hematologic care at large, echoing previous studies of hematologist perspectives. Palliative care physicians express enthusiasm for caring for these patients, desire for improved understanding of palliative care, and ongoing opportunities to improve hematology-specific knowledge and skills.
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Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States.
| | - Daniel S Childs
- Departments of Medicine and Oncology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kelly L Wu
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, United States
| | - Daniel K Partain
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Jacob J Strand
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
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5
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Gaster EE, Riemer CA, Aird JL, King BJ, El-Azhary RA, Wilson BD, Strand JJ, Wu KL, Cleary JF, Lohse CM, Lehman JS. Palliative care utilization in calciphylaxis: a single-center retrospective review of 121 patients (1999-2016). Int J Dermatol 2021; 61:455-460. [PMID: 34196998 DOI: 10.1111/ijd.15726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/03/2021] [Accepted: 05/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Calciphylaxis is a debilitating dermatological condition associated with high rates of morbidity and mortality. Palliative care offers a multidisciplinary approach to addressing symptoms and goals of care in patients with serious medical diagnoses. Involvement of palliative services for calciphylaxis is infrequently reported in the literature. The purpose of this report is to assess rates of palliative and pain consultation for patients with calciphylaxis. METHODS This is a comprehensive, single-institution retrospective chart review of 121 eligible patients with a diagnosis of calciphylaxis treated at Mayo Clinic in Rochester, Minnesota, from 1999 to 2016. Inclusion criteria were an indisputable diagnosis of calciphylaxis based on clinical, histopathologic, and radiographic features. One hundred twenty-one patients met inclusion criteria. RESULTS Fifty-one patients (42%) received either a palliative (n = 15) or pain (n = 20) consultation, or both (n = 16). Patients with a palliative care consultation were younger compared with those without (mean ages 57 vs. 62 years, P = 0.046). In 104 patients (86%), psychiatric symptoms were not assessed. CONCLUSIONS In this cohort of patients with calciphylaxis, the majority do not receive palliative and pain care consultations. Psychiatric complications are inconsistently addressed. These observations highlight practice gaps in the care of patients with calciphylaxis.
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Affiliation(s)
- Emily E Gaster
- Mayo Clinic Department of Dermatology, Rochester, MN, USA
| | | | - Jenna L Aird
- Mayo Clinic Department of Dermatology, Rochester, MN, USA
| | | | | | | | - Jacob J Strand
- Division of Palliative Care, Mayo Clinic Department of Medicine, Rochester, MN, USA
| | - Kelly L Wu
- Division of Palliative Care, Mayo Clinic Department of Medicine, Rochester, MN, USA
| | - James F Cleary
- Indiana University Health Palliative Care, Indianapolis, IN, USA
| | | | - Julia S Lehman
- Mayo Clinic Department of Dermatology, Rochester, MN, USA
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6
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Murphree DH, Wilson PM, Asai SW, Quest DJ, Lin Y, Mukherjee P, Chhugani N, Strand JJ, Demuth G, Mead D, Wright B, Harrison A, Soleimani J, Herasevich V, Pickering BW, Storlie CB. Improving the delivery of palliative care through predictive modeling and healthcare informatics. J Am Med Inform Assoc 2021; 28:1065-1073. [PMID: 33611523 DOI: 10.1093/jamia/ocaa211] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/28/2020] [Accepted: 02/16/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Access to palliative care (PC) is important for many patients with uncontrolled symptom burden from serious or complex illness. However, many patients who could benefit from PC do not receive it early enough or at all. We sought to address this problem by building a predictive model into a comprehensive clinical framework with the aims to (i) identify in-hospital patients likely to benefit from a PC consult, and (ii) intervene on such patients by contacting their care team. MATERIALS AND METHODS Electronic health record data for 68 349 inpatient encounters in 2017 at a large hospital were used to train a model to predict the need for PC consult. This model was published as a web service, connected to institutional data pipelines, and consumed by a downstream display application monitored by the PC team. For those patients that the PC team deems appropriate, a team member then contacts the patient's corresponding care team. RESULTS Training performance AUC based on a 20% holdout validation set was 0.90. The most influential variables were previous palliative care, hospital unit, Albumin, Troponin, and metastatic cancer. The model has been successfully integrated into the clinical workflow making real-time predictions on hundreds of patients per day. The model had an "in-production" AUC of 0.91. A clinical trial is currently underway to assess the effect on clinical outcomes. CONCLUSIONS A machine learning model can effectively predict the need for an inpatient PC consult and has been successfully integrated into practice to refer new patients to PC.
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Affiliation(s)
- Dennis H Murphree
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick M Wilson
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Shusaku W Asai
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Quest
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yaxiong Lin
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nirmal Chhugani
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob J Strand
- Division of Palliative Care, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel Demuth
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - David Mead
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian Wright
- Information Technology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Harrison
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalal Soleimani
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vitaly Herasevich
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian W Pickering
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Curtis B Storlie
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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7
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Havyer RD, Lapid MI, Dockter TJ, McCue SA, Stelpflug AJ, Bigelow ML, Robsahm MM, Elwood T, Strand JJ, Bauer BA, Cutshall SM, Sloan JA, Walton MP, Whitford KJ. Impact of Massage Therapy on the Quality of Life of Hospice Patients and Their Caregivers: A Pilot Study. J Palliat Care 2020; 37:41-47. [PMID: 33213233 DOI: 10.1177/0825859720975991] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Evidence for massage therapy (MT) in hospice patients remains limited. We conducted a prospective pilot study on MTs impact on quality of life of hospice patients and caregivers. Patient-caregiver dyads were enrolled if patients scored ≥5 on pain, depression, anxiety, or well-being using the revised Edmonton Symptom Assessment System Revised (ESAS-r). The patient received MT weekly for up to 3 massages with assessments completed at baseline, after each massage, and 1 week after the final massage for patients and at baseline and 1 week after final massage for caregivers. A satisfaction survey was completed at study completion. A pro-rated area under the curve (AUC) was utilized to assess the primary endpoints of change in ESAS-r for patient ratings of pain, depression and anxiety as well as the Linear Analogue Self-Assessment (LASA). Median difference scores (end of study value)-(baseline value) for each participant and caregiver were calculated. Of 27 patients and caregivers enrolled, 25 patients received MT. Fifteen patients completed all 3 MT sessions and were given the final symptom assessment and satisfaction survey and their caregivers completed final assessments. The proportion of patients considered success (AUC > baseline) in the primary endpoints were the following: pain 40.9%, depression 40.9%, anxiety 54.5%, LASA 54.5%. Median difference scores were largely zero indicating no significant temporal change in symptoms. Patients were highly satisfied with MT. This pilot study indicated that MT was a feasible and well-received intervention in our population of patients with inadequately controlled symptoms.
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Affiliation(s)
- Rachel D Havyer
- Mayo Clinic Center for Palliative Medicine, 195110Mayo Clinic, Rochester, MN, USA.,Division of Community Internal Medicine, Department of Medicine, 384842Mayo Clinic, Rochester, MN, USA
| | - Maria I Lapid
- Mayo Clinic Center for Palliative Medicine, 195110Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Hospice, 384842Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, 384842Mayo Clinic, Rochester, MN, USA
| | - Travis J Dockter
- Biomedical Statistics and Informatics, 384842Mayo Clinic, Rochester, MN, USA
| | - Shaylene A McCue
- Biomedical Statistics and Informatics, 384842Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Theresa Elwood
- Mayo Clinic Hospice, 384842Mayo Clinic, Rochester, MN, USA
| | - Jacob J Strand
- Mayo Clinic Center for Palliative Medicine, 195110Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Hospice, 384842Mayo Clinic, Rochester, MN, USA
| | - Brent A Bauer
- Division of Integrative Medicine & Health, Department of Medicine, 384842Mayo Clinic, Rochester, MN, USA
| | - Susanne M Cutshall
- Division of Integrative Medicine & Health, Department of Medicine, 384842Mayo Clinic, Rochester, MN, USA
| | - Jeff A Sloan
- Biomedical Statistics and Informatics, 384842Mayo Clinic, Rochester, MN, USA
| | - Monica P Walton
- Department of Psychiatry and Psychology, 384842Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Mayo Clinic Center for Palliative Medicine, 195110Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Hospice, 384842Mayo Clinic, Rochester, MN, USA.,Division of Hospital Internal Medicine, Department of Medicine, 384842Mayo Clinic, Rochester, MN, USA
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8
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Anand V, Vallabhajosyula S, Cheungpasitporn W, Frantz RP, Cajigas HR, Strand JJ, DuBrock HM. Inpatient Palliative Care Use in Patients With Pulmonary Arterial Hypertension: Temporal Trends, Predictors, and Outcomes. Chest 2020; 158:2568-2578. [PMID: 32800817 DOI: 10.1016/j.chest.2020.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disease associated with significant morbidity and mortality. Despite the negative impact of PAH on quality of life and survival, data on use of specialty palliative care services (PCS) is scarce. RESEARCH QUESTION We sought to evaluate the inpatient use of PCS in patients with PAH. STUDY DESIGN AND METHODS Using the National (Nationwide) Inpatient Sample, 30,495 admissions with a primary diagnosis of PAH were identified from 2001 through 2017. The primary outcome of interest was temporal trends and predictors of inpatient PCS use in patients with PAH. RESULTS The inpatient use of PCS was low (2.2%), but increased during the study period from 0.5% in 2001 to 7.6% in 2017, with a significant increase starting in 2009. White race, private insurance, higher socioeconomic status, hospital-specific factors, higher comorbidity burden (Charlson Comorbidity Index), cardiac and noncardiac organ failure, and use of extracorporeal membrane oxygenation and noninvasive mechanical ventilation were independent predictors of increased PCS use. PCS use was associated with a higher prevalence of do-not-resuscitate status, a longer length of stay, higher hospitalization costs, and increased in-hospital mortality with less frequent discharges to home, likely because these patients were also sicker (higher comorbidity index and illness acuity). INTERPRETATION The inpatient use of PCS in patients with PAH is low, but has been increasing over recent years. Despite increased PCS use over time, patient- and hospital-specific disparities in PCS use continue. Further studies evaluating these disparities and the role of PCS in the comprehensive care of PAH patients are warranted.
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Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Hector R Cajigas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jacob J Strand
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
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9
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Goldstein NE, Mather H, McKendrick K, Gelfman LP, Hutchinson MD, Lampert R, Lipman HI, Matlock DD, Strand JJ, Swetz KM, Kalman J, Kutner JS, Pinney S, Morrison RS. Improving Communication in Heart Failure Patient Care. J Am Coll Cardiol 2019; 74:1682-1692. [PMID: 31558252 PMCID: PMC7000126 DOI: 10.1016/j.jacc.2019.07.058] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. OBJECTIVES The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. METHODS In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. RESULTS A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. SECONDARY OUTCOMES Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. CONCLUSIONS The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).
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Affiliation(s)
- Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York.
| | - Harriet Mather
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Mathew D Hutchinson
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona College of Medicine Tucson, Tucson, Arizona
| | - Rachel Lampert
- Department of Internal Medicine, Section of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Hannah I Lipman
- Hackensack University Medical Center, Hackensack, New Jersey; Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
| | - Daniel D Matlock
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Jacob J Strand
- Division of General Internal Medicine, Department of Medicine, Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Birmingham Veterans Affairs Medical Center, Department of Medicine and UAB Center for Palliative and Supportive Care, University of Alabama Birmingham, Birmingham, Alabama
| | - Jill Kalman
- Lenox Hill Hospital, Northwell Health, New York, New York
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Sean Pinney
- Division of Cardiology, Samuel Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters Veterans Affairs Medical Center, Bronx, New York
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10
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Warner LL, Moeschler SS, Pittelkow TP, Strand JJ. Attitudes of Hospice Providers Regarding Intrathecal Targeted Drug Delivery for Patients With Cancer. Am J Hosp Palliat Care 2019; 36:955-958. [PMID: 31132860 DOI: 10.1177/1049909119852928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pain is one of the most commonly experienced and feared symptoms faced by patients with a serious illness. For these patients, intrathecal drug delivery systems (IDDSs) provide greater potency and/or few systemic side effects. However, despite these benefits, the integration and management of IDDS for patients receiving hospice care has not been previous studied. An electronic, 18-question survey was sent to 200 hospice practitioners (physicians, nurse practitioners and nurses) in the state of Minnesota to explore their experience, confidence, and the perceived barriers to caring for patients with IDDS while being cared for on hospice. Providers were identified though mailing lists from the Minnesota Network of Hospice and Palliative Care organization. The survey was administered by the Mayo Clinic Survey Research Center with institutional review board approval. Slightly more than 50% of respondents have ever cared for a patient with an intrathecal pump. If a patient had a pump in place, only 28% of providers expressed confidence in managing their pain. Additionally, only 3 of 10 respondents felt that adjusting an intrathecal pump should be the first option when a patient with an IDDS in place had increased pain. Indeed, the vast majority (over 80%) of respondents preferred the use of systemic therapies for primary pain management. Access to IDDS vendors for changes/refills in the home is identified as another barrier with over 50% of respondents either unaware of an available vendor or reporting no vendor available. There are numerous self-reported barriers to ongoing use of IDDS with patients receiving hospice care.
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Affiliation(s)
| | - Susan S Moeschler
- 2 Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Thomas P Pittelkow
- 2 Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Jacob J Strand
- 3 Division of Palliative Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Kamdar M, Centi AJ, Agboola S, Fischer N, Rinaldi S, Strand JJ, Traeger L, Temel JS, Greer J, El-Jawahri A, Jackson V, Kvedar J, Jethwani K. A randomized controlled trial of a novel artificial intelligence-based smartphone application to optimize the management of cancer-related pain. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11514 Background: Cancer pain is a significant problem that impairs patient quality of life and increases healthcare utilization. ePAL is a smartphone application that utilizes patient-reported outcomes (PROs) and artificial intelligence (AI) to optimize cancer pain management. This randomized controlled trial examined the impact of ePAL on cancer pain severity, attitudes toward cancer pain, and healthcare utilization. Methods: Patients with pain from metastatic solid tumors (n = 112) undergoing treatment in a palliative care clinic were randomized to either a control group (n = 56) that received usual care or an intervention group (n = 56) that received ePAL in addition to usual care for 8 weeks. Measures of pain severity (Brief Pain Inventory), attitudes towards cancer treatment (Barriers Questionnaire II) and anxiety (General Anxiety Disorder-7) were assessed. We used repeated measures mixed modeling to assess change in outcome measures over time. We also conducted a chart review to identify pain-related hospital admissions and emergency department (ED) visits and compared risk between study groups. Results: Pain severity (BPI) and negative attitudes toward cancer treatment (BQ-II) decreased significantly for those assigned to ePAL compared to controls (ß = -0.09, p = 0.034 and ß = -0.037, p = 0.042, respectively). Patients assigned to ePAL reported higher anxiety scores compared to controls (ß = 0.21, p = 0.015). Patients assigned to ePAL had significantly fewer pain-related hospital admissions (n = 4 vs. n = 20, per patient risk ratio 0.31, p = 0.018) and fewer pain-related admissions through the ED (n = 2 vs. n = 14, per patient risk ratio 0.18, p = 0.008) compared to control group. Conclusions: To our knowledge, this is the first mobile app to utilize patient reported outcomes and artificial intelligence to significantly decrease pain scores and pain-related hospitalizations in patients with cancer-related pain. Future directions include examining the efficacy of ePAL in settings with limited access to palliative care.
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Affiliation(s)
| | | | | | - Nils Fischer
- Connected Health Innovation, Partners Healthcare, Boston, MA
| | | | | | | | | | | | | | | | | | - Kamal Jethwani
- Connected Health Innovation, Partners Healthcare, Boston, MA
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12
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Wood C, Cutshall SM, Wiste RM, Gentes RC, Rian JS, Tipton AM, Ann-Marie D, Mahapatra S, Carey EC, Strand JJ. Implementing a Palliative Medicine Music Therapy Program: A Quality Improvement Project. Am J Hosp Palliat Care 2019; 36:603-607. [DOI: 10.1177/1049909119834878] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | - Rachel M. Wiste
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rachel C. Gentes
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Johanna S. Rian
- Dolores Jean Lavins Center for Humanities in Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Elise C. Carey
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob J. Strand
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Affiliation(s)
- Kelly L. Wu
- Center for Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Phoenix, Arizona
| | - Amanda K. Lorenz
- Center for Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelly J. Christensen
- Center for Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Molly A. Feely
- Center for Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elise C. Carey
- Center for Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jacob J. Strand
- Center for Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
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14
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Partain DK, Sanders JJ, Leiter RE, Carey EC, Strand JJ. End-of-Life Care for Seriously Ill International Patients at a Global Destination Medical Center. Mayo Clin Proc 2018; 93:1720-1727. [PMID: 30522592 DOI: 10.1016/j.mayocp.2018.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/27/2018] [Accepted: 08/14/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize the end-of-life care of all international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015. PATIENTS AND METHODS We performed a retrospective review of all adult international patients who died at a global destination medical center from January 1, 2005, through December 31, 2015. RESULTS Eighty-two international patients from 25 countries and 5 continents died during the study period (median age, 59.5 years; 59% male). Of the study cohort, 11% (n=9) completed an advance directive, 61% (n=50) died in the intensive care unit, 26% (n=21) had a full code order at the time of death, and 73% (n=19 of 26) receiving cardiopulmonary resuscitation did not survive the resuscitation process. CONCLUSION Seriously ill international patients who travel to receive health care in the United States face many barriers to receiving high-quality end-of-life care. Seriously ill international patients are coming to the United States in increasing numbers, and little is known about their end-of-life care. There are many unique needs in the care of this complex patient population, and further research is needed to understand how to provide high-quality end-of-life care to these patients.
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Affiliation(s)
- Daniel K Partain
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA
| | - Elise C Carey
- Section of Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Center for Palliative Medicine, Mayo Clinic, Rochester, MN
| | - Jacob J Strand
- Section of Palliative Medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Center for Palliative Medicine, Mayo Clinic, Rochester, MN.
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15
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Santivasi WL, Wu K, Litzow MR, LeBlanc TW, Strand JJ. Palliative care physicians' beliefs toward hematology and the care of patients with hematologic diseases: Results of a nationwide survey. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.34_suppl.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
95 Background: Palliative care (PC) specialists provide supportive care for patients with hematologic diseases (HD). However, the degree of engagement by PC physicians may be limited by the views of both PC physicians & hematologists. Prior studies have surveyed hematologists to identify barriers to delivery of PC, however PC physician views are unclear. This study aimed to examine views of PC physicians toward hematology. Methods: A survey was mailed to a random sample of the AAHPM physician contact list in 2017. Items focused on perceptions of their understanding of HD, comfort providing care, opinions regarding PC & hospice involvement, & beliefs about hematologists. Anonymized responses were assessed on a Likert scale. Statistical testing was based on logistic regression models with generalized estimating equations to account for correlated data within respondents. Results: 538 of 1000 surveys were completed. 51.9% of respondents were male. Community (37.2%), academic (36.7%) & hospice (26.2%) physicians were represented. Respondents were likelier to believe they understand the trajectories of lymphoma & myeloma than leukemia or patients undergoing hematopoietic stem cell transplantation (HSCT) (p < 0.001). They were more comfortable discussing prognosis (p < 0.001) & managing symptoms (p < 0.001) in lymphoma & myeloma than leukemia & HSCT. They were likelier to believe that hematologists’ perceptions of PC physicians limit collaboration rather than their own views of hematologists (p < 0.001). 80.2% agreed that hospice referrals are not made early enough. Conclusions: PC physicians’ understanding of trajectories & comfort caring for patients varies by hematologic disease. They perceive that hematologists’ perceptions are a larger barrier than their own & hospice referrals are delayed. These results provide insights into opportunities for better collaboration with hematologists.
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16
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Strand JJ, LeBlanc TW. Palliative care integration in haematological malignancies: towards a needs-based approach. BMJ Support Palliat Care 2018; 8:289-291. [DOI: 10.1136/bmjspcare-2018-001611] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/01/2018] [Indexed: 11/03/2022]
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17
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Warner NS, Bendel MA, Warner MA, Strand JJ, Gazelka HM, Hoelzer BC, Mauck WD, Lamer TJ, Kor DJ, Moeschler SM. Bleeding Complications in Patients Undergoing Intrathecal Drug Delivery System Implantation. Pain Med 2018; 18:2422-2427. [PMID: 28340041 DOI: 10.1093/pm/pnw363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction Intrathecal drug delivery systems (IDDSs) have dramatically improved analgesia and the functional status of cancer patients and those with chronic pain states. However, given the close proximity to the neuraxis and frequent concomitant use of antiplatelet or anticoagulant medications, this intervention is not without risk. The goal of this investigation was to determine the incidence of bleeding complications following IDDS placement. Methods This is a retrospective review from 2005 through 2014 of adult patients undergoing IDDS implantation or revision at a tertiary care center. The primary outcome was a bleeding-related neurological complication requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days. Results A total of 247 procedures were performed on 216 unique patients. Patients received aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) within seven days of needle placement for 64 procedures (25.9%). A preprocedural platelet count or international normalized ratio (INR) was available within 30 days for 138 procedures (55.9%). Of these, two patients had a platelet count lower than 100 x 109/L and one patient had an INR of 1.5 or higher at the time of the procedure. One neurological complication was identified (0.4%) that was not related to procedural bleeding. Similarly, three patients (1.2%) received a periprocedural red blood cell transfusion, none of which were related to procedural bleeding. Conclusion No cases of bleeding-related neurological complications were identified following IDDS placement or revision, including in those receiving aspirin or NSAIDs. Future investigations with larger numbers are needed to further explore the safety of antithrombotic therapy continuation or discontinuation periprocedurally.
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Affiliation(s)
| | | | | | - Jacob J Strand
- Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Halena M Gazelka
- Departments of Anesthesiology.,Pain Medicine.,Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Tim J Lamer
- Departments of Anesthesiology.,Pain Medicine
| | - Daryl J Kor
- Departments of Anesthesiology.,Critical Care Medicine
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18
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Mueller PS, Strand JJ, Tilburt JC. Voluntarily Stopping and Eating and Drinking Among Patients With Serious Advanced Illness-A Label in Search of a Problem? JAMA Intern Med 2018; 178:726-727. [PMID: 29801130 DOI: 10.1001/jamainternmed.2018.1150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paul S Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.,Office of Clinical Ethics and Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
| | - Jacob J Strand
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.,Section of Palliative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jon C Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.,Office of Clinical Ethics and Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
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19
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Pittelkow TP, Wu KL, Strand JJ, Moeschler SM. Opioid Neurotoxicity Treated with Intrathecal Drug Delivery System Implant. J Palliat Med 2018; 21:126. [DOI: 10.1089/jpm.2017.0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas P. Pittelkow
- Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
- Center for Palliative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Kelly L. Wu
- Center for Palliative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jacob J. Strand
- Center for Palliative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Susan M. Moeschler
- Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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20
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Strand JJ, Warner LL, Kamdar MM, Flaherty AW, Jackson VA. It is Electric! Electroconvulsive Therapy for Refractory Central Pain and Comorbid Psychiatric Disease. J Palliat Med 2018; 21:266-268. [PMID: 29327970 DOI: 10.1089/jpm.2017.0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Central pain syndromes are a complex, diverse group of clinical conditions that are poorly understood. We present a patient with progressive, debilitating central pain and co-existing mood disorders that was refractory to multimodal pharmacologic and nonpharmacologic therapies, but that ultimately responded to electroconvulsive therapy (ECT). The patient described it at various times as her skin being "lit on fire," "stabbed," "squeezed like a boa constrictor," or itching unbearably. She underwent a course of three sequential ECT treatments during her hospitalization and it dramatically decreased her pain. She began maintenance ECT, and a rate of roughly one treatment a month provided persistent pain suppression. Despite this lack of evidence, ECT has a favorable safety profile and can be considered in the therapeutic armamentarium for patients who have exhausted standard treatment regimens who continue to have suffering in the setting of central pain syndromes and coexisting mood disorders.
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Affiliation(s)
- Jacob J Strand
- 1 Division of General Internal Medicine, Center for Palliative Medicine , Mayo Clinic, Rochester, Minnesota
| | - Lindsay L Warner
- 2 Department of Anesthesiology, Mayo Clinic , Rochester, Minnesota
| | - Mihir M Kamdar
- 3 Division of Palliative Care & Geriatrics, Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts.,4 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital , Boston, Massachusetts
| | - Alice W Flaherty
- 5 Department of Neurology, Massachusetts General Hospital , Boston, Massachusetts
| | - Vicki A Jackson
- 3 Division of Palliative Care & Geriatrics, Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts
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21
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Young KA, Redfield MM, Strand JJ, Dunlay SM. End-of-Life Discussions in Patients With Heart Failure. J Card Fail 2017; 23:821-825. [PMID: 28842378 DOI: 10.1016/j.cardfail.2017.08.451] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 08/09/2017] [Accepted: 08/16/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although guidelines call on clinicians to conduct regular conversations about advance care planning and end-of-life (EOL) preferences with patients with heart failure (HF), research suggests that physicians often avoid these discussions. METHODS AND RESULTS From January 20, 2014, to January 18, 2016, Southeastern Minnesota residents hospitalized with acute decompensated HF (ADHF) at Mayo Clinic hospitals were enrolled into an observational cohort study that included the administration of face-to-face questionnaires. Risk of death (prognosis) was estimated using the Meta-analysis Global Group in Chronic Heart Failure score. Among 400 patients (mean age 77.7 years, 46% female, 48% preserved ejection fraction), only 69 (17%) reported previously discussing EOL wishes with their physician. Patients reporting EOL discussions more often had an advance directive (81% vs 66%; P = .009), recognized the term "hospice" (96% vs 87%; P = .027), and had more favorable attitudes of dying and hospice (P = .030). Resuscitation preferences and rates of completion of advance directives varied with prognosis, although patient-clinician EOL discussions did not. CONCLUSIONS The majority of patients hospitalized with ADHF did not recall discussing their preferences for EOL care with their physician. This represents an important modifiable gap in the optimal longitudinal care of HF patients.
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Affiliation(s)
| | | | - Jacob J Strand
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shannon M Dunlay
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
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22
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Dunlay SM, Strand JJ, Wordingham SE, Stulak JM, Luckhardt AJ, Swetz KM. Dying With a Left Ventricular Assist Device as Destination Therapy. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003096. [PMID: 27758809 DOI: 10.1161/circheartfailure.116.003096] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 09/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the ability of left ventricular assist device as destination therapy (DT-LVAD) to prolong survival for many patients with advanced heart failure, little is known about the eventual end-of-life care that patients with DT-LVAD receive. METHODS AND RESULTS All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota, from January 1, 2007, to September 30, 2014, who subsequently died before July 1, 2015, were included. Information about end-of-life care was obtained from documentation in the electronic medical record. Of 89 patients who died with a DT-LVAD, the median (25th-75th percentile) time from left ventricular assist device implantation to death was 14 (4-31) months. The most common causes of death were multiorgan failure (26%), hemorrhagic stroke (24%), and progressive heart failure (21%). Nearly half (46%) of the patients saw palliative care within 1 month before death; however, only 13 (15%) patients enrolled in hospice a median 11 (range 1-315) days before death. Most patients (78%) died in the hospital, of which 88% died in the intensive care unit. In total, 49 patients had their left ventricular assist device deactivated before death, with all but 3 undergoing deactivation in the hospital. Most patients died within an hour of left ventricular assist device deactivation and all within 26 hours. CONCLUSIONS In contrast to the general heart failure population, most patients with DT-LVAD die in the hospital and few use hospice. Further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.
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Affiliation(s)
- Shannon M Dunlay
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.).
| | - Jacob J Strand
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Sara E Wordingham
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - John M Stulak
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Angela J Luckhardt
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Keith M Swetz
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
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23
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Abstract
More than 120,000 US patients were listed for solid organ transplants in 2016. Although data are scarce, we suspect that many of these patients will die while awaiting transplant and without engaging in goals-of-care discussions with their physicians. The challenges of addressing goals of care in patients with malignancy, end-stage renal disease, and heart failure have been studied. However, there is sparse literature on addressing goals of care throughout the dynamic process of transplant assessment and listing. We propose the concept of an organ transplant imperative, which is the perceived obligation by patients and health care providers to proceed with organ transplant and to avoid advance care planning and triggered goals-of-care discussions, even in situations in which patients' clinical trajectories have worsened, resulting in poor quality of life and low likelihood of meaningful survival. We situate this concept within the paradigms of clinical inertia and the treatment and technological imperatives. We illustrate this concept by describing a patient with end-stage liver disease (ESLD) who was hoping for a liver transplant, who was caught between the conflicting perspectives of specialist and primary care physicians, and who died of complications of ESLD without experiencing the benefits of advance care planning. Greater awareness of the transplant imperative should generate a shared understanding among specialists, generalists, and patients and will provide opportunities for more formalized involvement of palliative medicine experts in the care of transplant patients.
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Affiliation(s)
| | - Jacob J Strand
- Section of Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Paul S Mueller
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Thomas J Beckman
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
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24
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Young KA, Wordingham SE, Strand JJ, Roger VL, Dunlay SM. Discordance of Patient-Reported and Clinician-Ordered Resuscitation Status in Patients Hospitalized With Acute Decompensated Heart Failure. J Pain Symptom Manage 2017; 53:745-750. [PMID: 28062350 PMCID: PMC5373999 DOI: 10.1016/j.jpainsymman.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/25/2016] [Accepted: 11/14/2016] [Indexed: 01/11/2023]
Abstract
CONTEXT Accurate documentation of preferences for cardiopulmonary resuscitation at hospital admission is critical to ensure that patients receive resuscitation or not in accordance with their wishes. OBJECTIVES We sought to identify and characterize inconsistencies in patient-reported and clinician-ordered resuscitation status in patients hospitalized with acute decompensated heart failure (ADHF). METHODS Southeastern Minnesota residents hospitalized with ADHF were prospectively enrolled into a study that included the administration of face-to-face questionnaires from January 2014 to February 2016. Patient-reported resuscitation status was assessed at enrollment using a validated question. Clinician-ordered resuscitation preferences at hospital admission were abstracted from the electronic medical record. RESULTS Of the 400 patients administered the questionnaire; 213 (53.3%) stated their resuscitation preference as Full Code, 166 (41.5%) do-not-resuscitate (DNR), and 21 (5.3%) were unsure. In comparison, clinician-ordered resuscitation status was Full Code in 263 (65.8%) patients, DNR in 133 (33.3%), and not documented in four (1.0%). Patient-reported and clinician-ordered resuscitation status was discordant in 20% of patients, of whom 5.6% elected Full Code by questionnaire and had a DNR clinician order, and 14.4% elected DNR by questionnaire but had a Full Code clinician order. Differences in age, comorbidities, health literacy, marital status, completion of advance directives, hospital length of stay, and discharge destination in patients with discordant vs. concordant resuscitation preferences were observed. CONCLUSIONS Patient-reported and clinician-ordered resuscitation preferences were discordant in 20% of patients hospitalized with ADHF. The underlying etiology of these inconsistencies may reflect factors such as patient indecisiveness or patient-clinician miscommunication and requires further exploration.
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Affiliation(s)
| | | | - Jacob J Strand
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vėronique L Roger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon M Dunlay
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.
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Partain DK, Ingram C, Strand JJ. Providing Appropriate End-of-Life Care to Religious and Ethnic Minorities. Mayo Clin Proc 2017; 92:147-152. [PMID: 28062060 DOI: 10.1016/j.mayocp.2016.08.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/22/2016] [Accepted: 08/24/2016] [Indexed: 11/25/2022]
Abstract
There is overwhelming evidence that racial and ethnic minorities face multiple health care disparities. Recognizing and addressing cultural and religious/spiritual (RS) values is a critical aspect of providing goal-concordant care for patients facing a serious illness, especially at the end of life. Failure to address a patient's cultural and RS needs can lead to diminished quality of care and worse health outcomes. Given the multitude of cultural and RS values, we believe that a framework of cultural and RS curiosity along with a willingness to engage patients in discussions about these elements of their care within an interdisciplinary team should be the goal of all providers who are discussing goals, preferences, and values with patients facing advanced terminal illness.
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Affiliation(s)
| | - Cory Ingram
- Division of Palliative Medicine, Mayo Clinic, Rochester, MN
| | - Jacob J Strand
- Division of Palliative Medicine, Mayo Clinic, Rochester, MN.
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Young KA, Wordingham SE, Strand JJ, Roger VL, Dunlay SM. Discordance of Patient-Reported and Clinician-Ordered Resuscitation Status in Patients Hospitalized with Acute Decompensated Heart Failure. J Card Fail 2016. [DOI: 10.1016/j.cardfail.2016.06.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
We present the case of a 34-year-old woman with Klippel-Feil syndrome who developed progressive generalized dystonia of unclear etiology, resulting in intractable pain despite aggressive medical and surgical interventions. Ultimately, palliative sedation was required to relieve suffering. Herein, we describe ethical considerations including defining sedation, determining prognosis in the setting of an undefined neurodegenerative condition, and use of treatments that concurrently might prolong or alter end-of-life trajectory. We highlight pertinent literature and how it may be applied in challenging and unique clinical situations. Finally, we discuss the need for expert multidisciplinary involvement when implementing palliative sedation and illustrate that procedures and rules need to be interpreted to deliver optimal patient-centered plan of care.
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Affiliation(s)
- Jacob J. Strand
- Division of General Internal Medicine, Department of Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly A. Feely
- Division of General Internal Medicine, Department of Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Neha M. Kramer
- Division of General Internal Medicine, Department of Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Susan M. Moeschler
- Division of Pain Medicine Mayo Clinic, Department of Anesthesiology, Rochester, MN, USA
| | - Keith M. Swetz
- Division of General Internal Medicine, Department of Medicine, Section of Palliative Medicine, Mayo Clinic, Rochester, MN, USA
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Dunlay SM, Strand JJ, Wordingham SE, Stulak JM, Kushwaha SS, Luckhardt A, Swetz KM. Abstract 20: Dying With a Left Ventricular Assist Device as Destination Therapy. Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Left ventricular assist devices as destination therapy (DT-LVAD) have been shown to decrease mortality compared with medical management, and can improve quality of life for many patients with advanced heart failure. However, while most patients live longer with DT-LVAD than they would have with medical therapy, deaths still occur. We sought to systematically examine the end-of-life care of patients who died with a DT-LVAD at a single center.
Methods:
All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota from January 1, 2007 through September 30, 2014 who subsequently died prior to July 1, 2015 were included. The cause of death was determined based on review of documentation in the electronic medical record, including autopsy reports, death certificates and clinical notes. Details about palliative care consultations, hospice enrollment, hospitalizations, and device deactivation at the end-of-life were obtained from the electronic medical record.
Results:
Of 89 patients that died with a DT-LVAD (84 HeartMate II, 3 HeartWare, 2 Heartmate XVE, mean age at death 66.1 years), the mean (standard deviation) time from LVAD implantation to death was 2.0 (1.9) years. The most common causes of death were multiorgan failure (25.9%), hemorrhagic stroke (24.7%), and progressive heart failure (20.0%). Nearly half (45.6%) of patients saw palliative care in consultation within a month prior to death. However, only 13 (15.5%) patients enrolled in hospice a median of 11 (range 1-315) days prior to death, including 4 patients with concurrent cancer, 2 with stroke, and 7 with multiorgan failure. The vast majority of patients (78.6%) died in the hospital, and of those hospitalized at death, 87.7% died in the intensive care unit. Most patients hospitalized at death transitioned to a comfort-directed approach to care within 24 hours of dying. In total, 43 (48.3%) patients had their LVAD deactivated prior to death, with all but 3 undergoing deactivation in the hospital. The vast majority of patients died within an hour of LVAD deactivation, and all within 26 hours.
Conclusions:
In contrast to the general heart failure population, most patients with DT-LVAD die in the hospital and very few enroll in hospice. A significant body of research has demonstrated that patients who die in the intensive care unit and the hospital, as opposed to home or with hospice assistance, experience worse quality of life, quality of death and caregiver outcomes. Potential reasons that patients with DT-LVAD may experience different end-of-life care than other patients with heart failure exist, including that they often experience sudden changes in health status prior to death from acute events such as hemorrhagic stroke. However, further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.
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Dunlay SM, Foxen JL, Cole T, Feely MA, Loth AR, Strand JJ, Wagner JA, Swetz KM, Redfield MM. A survey of clinician attitudes and self-reported practices regarding end-of-life care in heart failure. Palliat Med 2015; 29:260-7. [PMID: 25488909 DOI: 10.1177/0269216314556565] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND As heart failure often follows an unpredictable clinical trajectory, there has been an impetus to promote iterative patient-provider discussions regarding prognosis and preferences for end-of-life care. AIM To examine clinicians' practices, expectations, and personal level of confidence in discussing goals of care and providing end-of-life care to their patients with heart failure. DESIGN Multi-site clinician survey. SETTING AND PARTICIPANTS Physicians, nurse practitioners, and physician assistants at Mayo Clinic (Rochester, Minnesota, USA) and its surrounding health system were asked to participate in an electronic survey in October 2013. Tertiary Care Cardiology, Community Cardiology, and Primary Care clinicians were surveyed. RESULTS A total of 95 clinicians participated (52.5% response rate). Only 12% of clinicians reported having annual end-of-life discussions as advocated by the American Heart Association. In total, 52% of clinicians hesitated to discuss end-of-life care citing provider discomfort (11%), perception of patient (21%) or family (12%) unreadiness, fear of destroying hope (9%), or lack of time (8%). Tertiary and Community Cardiology clinicians (66%) attributed responsibility for end-of-life discussions to the heart failure cardiologist, while 66% of Primary Care clinicians felt it was their responsibility. Overall, 30% of clinicians reported a low or very low level of confidence in one or more of the following: initiating prognosis or end-of-life discussions, enrolling patients in hospice, or providing end-of-life care. Most clinicians expressed interest in further skills acquisition. CONCLUSION Clinicians vary in their views and approaches to end-of-life discussions and care. Some lack confidence and most are interested in further skills acquisition.
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Affiliation(s)
- Shannon M Dunlay
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Jilian L Foxen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Terese Cole
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly A Feely
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ann R Loth
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob J Strand
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jean A Wagner
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Margaret M Redfield
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Rodriguez-Miranda R, Swetz KM, Hernández-Ortiz A, Strand JJ, Lara-Solares A, Hernández-Martinez EE, Tamayo-Valenzuela A, De la Fuente JR. Palliative sedation: Clinical practice challenges in Mexico and development of a national protocol for Mexico. Progress in Palliative Care 2015. [DOI: 10.1179/1743291x15y.0000000001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Dunlay SM, Foxen JL, Cole T, Feely MA, Loth AR, Strand JJ, Swetz KM, Wagner JA, Redfield MM. Abstract 352: Clinician Attitudes and Self-Reported Practices Regarding End of Life Care in Heart Failure. Circ Cardiovasc Qual Outcomes 2014. [DOI: 10.1161/circoutcomes.7.suppl_1.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Heart failure (HF) is a clinical syndrome with an overall poor prognosis, but the clinical trajectory is often unpredictable in individuals. There has been an impetus to promote iterative patient-provider discussions regarding preferences for end of life (EOL) care and advanced care planning. However, very little is known regarding provider preferences or their personal confidence addressing EOL care with their patients with HF. To address these gaps in knowledge, we surveyed clinicians at three practice sites in a large integrated health system.
Methods:
Physicians, nurse practitioners (NP), and physician assistants (PA) at Mayo Clinic (Rochester, Minnesota) and its surrounding health system were asked to participate in an electronic survey in October 2013. Clinicians surveyed included tertiary care HF specialists (Tertiary Care Cardiology), cardiologists and NP/PAs practicing in a community setting (Community Cardiology), and primary care clinicians (Primary Care).
Results:
A total of 95 clinicians completed the survey (52.5% response rate), including 50 physicians and 45 NP/PAs. Clinicians reported discussing prognosis and EOL wishes when their patient’s health status was worsening, but only 12% reported annual discussions as advocated by the American Heart Association. In total 52% of providers reported one or more reasons that they hesitate to discuss EOL care with their patients, including provider discomfort (11%), perception of patient (21%) or family (12%) unreadiness to have the discussion, fear of destroying hope (9%), or a lack of time (8%). Tertiary Care (63%) and Community Cardiology (58%) clinicians were more likely to attribute responsibility for having EOL discussions to the HF cardiologist, while 66% of Primary Care providers felt it was their responsibility. Tertiary and Community Cardiology clinicians were more likely to have referred patients to Palliative Medicine within the last year than Primary Care (89% vs. 21%, p<0.001). Overall, 30% of those surveyed reported low or very low confidence levels in initiating prognosis or EOL discussions, enrolling patients in hospice, or providing EOL care, with lower confidence among those with fewer years of clinical experience. The majority of clinicians expressed a high level of interest in further skills acquisition on these topics.
Conclusion:
There is tremendous variability in the way that clinicians view and approach advanced care discussions with their patients with HF; varying provider perception and lack of provider confidence may contribute. Despite this variability, most clinicians are interested in further development and skills acquisition. Addressing the learning needs of providers is an important next step toward enhancing the EOL care of patients with HF.
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Strand JJ, Mansel JK, Swetz KM. The growth of palliative care. Minn Med 2014; 97:39-43. [PMID: 25029799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Palliative care specialists focus on meeting the needs of patients with serious and/or life-threatening illnesses. These physicians have expertise in managing complex pain and nonpain symptoms, providing psychosocial and spiritual support to patients and their families, and communicating about complex topics and advance care planning. The American Board of Medical Specialties has allowed 10 of its member boards to co-sponsor certification in Hospice and Palliative Medicine. Thus, physicians from specialties ranging from pediatrics to surgery now practice hospice and palliative medicine. At the core of this field, however, are physicians who trained as internists and are boarded by the American Board of Internal Medicine. This article discusses the central principles of palliative care and explores its growth in two areas: oncology and critical care medicine.
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Strand JJ, Kamdar MM, Carey EC. Top 10 things palliative care clinicians wished everyone knew about palliative care. Mayo Clin Proc 2013; 88:859-65. [PMID: 23910412 DOI: 10.1016/j.mayocp.2013.05.020] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 12/25/2022]
Abstract
With a focus on improving quality of life for patients, palliative care is a rapidly growing medical subspecialty focusing on the care of patients with serious illness. Basic symptom management, discussions of prognostic understanding, and eliciting treatment goals are essential pieces in the practice of nearly all physicians. Nonetheless, many complex patients with a serious, life-threatening illness benefit from consultation with palliative care specialists, who are trained and experienced in complex symptom management and challenging communication interactions, including medical decision making and aligning goals of care. This article discusses the changing role of modern palliative care, addresses common misconceptions, and presents an argument for early integration of palliative care in the treatment of patients dealing with serious illness.
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Affiliation(s)
- Jacob J Strand
- Department of Internal Medicine, Palliative Care Section, Mayo Clinic, Rochester, MN.
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Strand JJ, Billings JA. Integrating palliative care in the intensive care unit. ACTA ACUST UNITED AC 2012; 10:180-7. [PMID: 22819446 DOI: 10.1016/j.suponc.2012.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 05/30/2012] [Accepted: 06/06/2012] [Indexed: 12/25/2022]
Abstract
The admission of cancer patients into intensive care units (ICUs) is on the rise. These patients are at high risk for physical and psychosocial suffering. Patients and their families often face difficult end-of-life decisions that highlight the importance of effective and empathetic communication. Palliative care teams are uniquely equipped to help care for cancer patients who are admitted to ICUs. When utilized in the ICU, palliative care has the potential to improve a patient's symptoms, enhance the communication between care teams and families, and improve family-centered decision making. Within the context of this article, we will discuss how palliative care can be integrated into the care of ICU patients and how to enhance family-centered communication; we will also highlight the care of ICU patients at the end of life.
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Affiliation(s)
- Jacob J Strand
- Palliative Care Service, Department of Medicine, Massachusetts General Hospital, Boston, USA.
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Gangat N, Strand JJ, Lasho TL, Li CY, Pardanani A, Tefferi A. Pruritus in polycythemia vera is associated with a lower risk of arterial thrombosis. Am J Hematol 2008; 83:451-3. [PMID: 18257107 DOI: 10.1002/ajh.21156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Among 418 patients with polycythemia vera seen at our institution and in whom pruritus history was recorded, the presence of pruritus at diagnosis was documented in 131 (31%) and its absence in 287 (69%). Pruritus was less frequently reported by smokers (12% vs. 24%; P = 0.004) and diabetics (5% vs. 11%; P = 0.04). The presence of pruritus was associated with a lower rate of arterial thrombosis, both at diagnosis (8% vs. 17%; P = 0.01) and during follow-up (16% vs. 30%; P = 0.003). Multivariable analysis revealed that these associations were independent of other risk factors for thrombosis. High JAK2V617F allele burden clustered with pruritus (P = 0.002) but did not affect thrombosis rates.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Department of Medicine and Laboratory Medicine, Mayo Clinic, Rochester, Minnesota55905, USA
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Tefferi A, Strand JJ, Lasho TL, Knudson RA, Finke CM, Gangat N, Pardanani A, Hanson CA, Ketterling RP. Bone marrow JAK2V617F allele burden and clinical correlates in polycythemia vera. Leukemia 2007; 21:2074-5. [PMID: 17476276 DOI: 10.1038/sj.leu.2404724] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tefferi A, Strand JJ, Lasho TL, Elliott MA, Li CY, Mesa RA, Dewald GW. Respective clustering of unfavorable and favorable cytogenetic clones in myelofibrosis with myeloid metaplasia with homozygosity for JAK2(V617F) and response to erythropoietin therapy. Cancer 2006; 106:1739-43. [PMID: 16532437 DOI: 10.1002/cncr.21787] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients who have myelofibrosis with myeloid metaplasia (MMM) display recurrent, albeit nonspecific cytogenetic abnormalities that are diverse prognostically. For the current study, the authors explored the relation between specific cytogenetic clones and JAK2(V617F) mutational status in patients with MMM and the effects on treatment response to erythropoietin (Epo). METHODS Concomitantly collected blood granulocytes and bone marrow were processed for JAK2(V617F) mutation analysis and cytogenetic studies, respectively. Genomic DNA was amplified by polymerase chain reaction, and fluorescent dye chemistry sequencing was performed by using the same primers that were used for amplification. RESULTS Among 105 study patients, cytogenetic abnormalities were detected in 47 patients (45%), and the JAK2(V617F) mutation was detected in 52 patients (50%). Comparison of mutational frequencies between favorable (normal, sole 13q-, or 20q- clones; n = 70 patients) and unfavorable (all other abnormalities; n = 35 patients) cytogenetic categories revealed a significantly different incidence of homozygous JAK2(V617F) between them (9% vs. 23%, respectively; P = .04). Furthermore, the mutant allele coexisted with several recurrent cytogenetic lesions. Among 25 patients who received Epo either alone (n = 17 patients) or in combination with hydroxyurea (n = 8 patients), 4 patients (16%) achieved a response, and none of them were homozygous for JAK2(V617F). Conversely, a response was more likely (P = .0001) in the presence of favorable cytogenetic abnormalities (i.e., 3 of 4 responders carried sole 13q- or 20q- clones). CONCLUSIONS Unfavorable and favorable cytogenetic clones in MMM clustered with homozygosity for JAK2(V617F) and treatment response to Epo-based therapy, respectively.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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